Strengthening public health systems in China
Authors: Qingyue Meng
Journal: The Lancet Public Health (2022)

Between 2009 and 2019, China implemented a comprehensive health system reform with strong political and financial supports, of which strengthening public health systems is one of the reform priorities.1Central Committee of the Communist Party of ChinaOpinions on deepening health system reform.http://www.gov.cn/test/2009-04/08/content_1280069.htmDate: 2009Date accessed: July 12, 2022Google Scholar To improve access to public health care, China initiated an essential public health programme covering a package of public health services with government subsidies from 2009.1Central Committee of the Communist Party of ChinaOpinions on deepening health system reform.http://www.gov.cn/test/2009-04/08/content_1280069.htmDate: 2009Date accessed: July 12, 2022Google Scholar An amount of ¥84 per capita was budgeted for this programme in 2022.2China National Health CommissionChina Ministry of FinanceNational Administration of Traditional Chinese MedicinePer capita 84 RMB Yuan is budgeted for the essential public health program in 2022.http://www.gov.cn/xinwen/2022-07/07/content_5699779.htmDate: 2022Date accessed: July 12, 2022Google Scholar In the meantime, investments to strengthen the capacity of the primary health-care system and specialised public health organisations such as Centers for Disease Prevention and Control (CDCs) have been increased. Although there is no doubt that the reform has improved public health systems to some extent, several challenges remain. For example, the function and capability of current public health systems cannot take the lead responsibility as expected in organising and implementing the Healthy China initiative.3Mao A Meng Y Yan X et al.Responsibilities and mission of the Public Health System in promoting the development of Healthy China.Chin J Publ Health. 2021; 9: 1313-1318Google Scholar The COVID-19 outbreak revealed more weaknesses and problems with public health systems, making strengthening of public health systems an urgent priority. China's public health has been facing two fundamental challenges. First, health-care delivery systems are fragmented. Health organisations and providers are not well coordinated in providing health care to community people for both non-communicable diseases and infectious diseases such as COVID-19 control. The government has tried to increase continuity of care by establishing medical alliances and groups within counties and cities, but integration mechanisms are needed, and it will take time to succeed. The fragmented health-care system mainly roots from the fragmented financing system. Health-care providers are financed through four channels: social health insurance schemes, regular government health budget, essential public health programmes, and out-of-pocket payments. These financial sources are managed by different authorities without effective coordination in budget management and allocation. Hospitals and clinics are reluctant to provide public health care due to the absence of financial incentives and the important number of regulations, which furthers separate hospitals and CDCs. Second, health spending is disease centred. The Healthy China initiative aims to shift the health system from disease centred to public health centred, emphasising the importance of health prevention and promotion. However, it is not easy to make these changes happen, because it requires changes in public policies. Over the past decade, the total health expenditure increased from ¥1090 per capita in 2008 to ¥4700 per capita in 2019, increasing by 331%.4China National Bureau of StatisticsChina Statistical Yearbook 2020. China Statistics Press, Beijing2022Google Scholar But although the absolute amount of spending for specialised public health organisations increased, its share in total health expenditure declined from 8·58% in 2008 to 5·47% in 2019, as more spending was used in hospitals.5China National Health CommissionChina Health Statistical Yearbook 2021. Peking Union Medical College Press, Beijing2022Google Scholar A similar trend can be seen in changes of shares of the health professionals in CDCs. Between 2012 and 2017, many young professionals left CDCs, with an average annual dropout rate of 0·5%; meanwhile, the hospital sector had a 6% annual increase rate of health professionals.6China National Health CommissionChina health statistical Yearbook 2018. Peking Union Medical College Press, Beijing2018Google Scholar Low-income and scarce opportunities for professional development are the main reasons for people leaving CDCs. A health-centred system has not been fully supported by public policies in finance and personnel management. To strengthen public health systems, a whole system approach needs to be adopted, focusing on three priorities: governance, financing, and service. First, a responsibility system for public health by all related authorities and organisations should be strengthened to support implementation of health in all policies. Both central and local governments should be accountable for the performance of public health systems. Digital health systems should be developed to improve public health regulations and evaluations. Second, a strategic purchasing mechanism should be used for allocation and distribution of health resources. Health funds should be equitably and efficiently used. A public health-oriented evaluation mechanism in which provision of preventive care and health outcomes are prioritised could be explored in assessing appropriateness of health resources allocation. Hospital-centric financing systems should be changed to support preventive and primary care, which is the most cost-effective way to invest in health care.7Hanson K Brikci N Erlangga D et al.The Lancet Global Health Commission on financing primary health care: putting people at the centre.Lancet Glob Health. 2022; 10: e715-e772Summary Full Text Full Text PDF PubMed Scopus (22) Google Scholar, 8The Lancet Public HealthStrengthening public health in China.Lancet Public Health. 2020; 5: e628Summary Full Text Full Text PDF PubMed Scopus (2) Google Scholar In the meantime, investment for health should be secured when economic growth is slowed (eg, by the COVID-19 pandemic). Third, support to a primary-care based system should be maintained. The government has made lots of efforts to improve the three tier health-care delivery system, including strengthening capacity of primary health-care providers and coordinating development and operation of different levels of health institutions. Continuity of the efforts is crucial because a shift in health-care delivery system takes time. Strengthening public health systems has been central to China's health reform workplans since the COVID-19 outbreak. In 2022, the central government listed four work priorities for strengthening public health capacity, including strengthening capacity of disease prevention by improving the network of disease prevention and capacity building of public health professionals, coordinating health teams and institutions working together for managing major diseases such as cancer and strokes, and incentivising hospitals and clinicians to provide health education and promotion by using appropriate evaluation indicators.9China State CouncilMajor task for deepening health system reform in 2020.http://www.gov.cn/zhengce/content/2022-05/25/content_5692209.htmDate: 2022Date accessed: July 17, 2022Google Scholar Strengthening public health systems is key to achieving universal health coverage in every country. China has moved in the right direction, and could have a much stronger public health system in the future with continued efforts. I declare no competing interests. The fate of public health in ChinaThis December issue of The Lancet Public Health is again dedicated to public health in China. China hosts a fifth of the world's population—the state and fate of public health in China are important for the achievement of the Sustainable Development Goals and to the health of populations outside China, as COVID-19 proved. While for many 2022 marked an exit from the COVID-19 pandemic mitigations and interventions, for millions in China this year has remained associated with strict lockdowns. The sustained zero-COVID strategy in which the country has embarked comes with a cost, and questions, that cannot be disregarded. Full-Text PDF Open Access